Keystone ECMO meeting 2018: To better characterize the frequency of bacterial and/or fungal coinfections in patients with viral pneumonias placed on ECMO and to understand their impact on mortality.

1. The Significance of Bacterial and Fungal Coinfection in the Setting of Viral
Pneumonia in Pediatric Patients on ECMO: An Analysis of the ELSO Registry
BACKGROUND
METHODS
CONCLUSION
RESULTS
A total of 4639 patients were identified as having met
inclusion criteria for the study. However, 1783
patients were excluded from analysis due to lack of
specific viral etiology, and another 6 were excluded
due to lack of outcome. Therefore, 2852 patients
were eligible for analysis.
RSV was the most common viral etiology, occurring
in 38.5% of patients, followed by adenovirus
(14.7%), enterovirus (13.5%) and influenza A
(12.6%). Overall survival of patients with viral
pneumonia was 56.6%.
Bacterial coinfections occurred in 30.9%.
Staphylococcus aureus was the most common
coinfection, occurring in 8.6% of total patients,
followed by Pseudomonas (4.8%), Enterococcus
(2.3%), H influenzae (2.2%), Strep pneumonia
(2.1%) and E coli (2%). No overall relationship found
to mortality (p=0.29). However, with regard to
Influenza A, there did appear to be a relationship
between coinfection and mortality (p=0.04).
Fungal infections occurred in only 7.3% of patients.
Candida albicans was the most frequently identified
fungus, found in 2.9% of total patients. Fungal
coinfections resulted in a significantly increased risk
of mortality (p=0.005), with a relative risk of mortality
of 1.24 (CI 1.08-1.42).
Ryan D Coleman, MD1,2
, Corey Chartan, DO1,2
, Marc A Anders, MD1
, James A Thomas, MD1
1
Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
2
Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
A query of the ELSO registry was performed in order to
identify all pediatric patients placed on mechanical
support between January 1985 and June 2017.
After identification of appropriate patients, statistical
analyses were carried out using JMP® 13 by SAS.
General descriptive statistics, as well as multivariate
analyses were performed to assess for significance.
RESULTS
Fungus Patients % Total Patients
Candida albicans 83 2.9
Yeast sp 44 1.5
Candida sp 37 1.3
Candida parapsilosis 29 1.0
Aspergillus sp 20 0.7
Candida tropicalis 12 0.4
Aspergillus fumigatus 11 0.4
Candida krusei 2 0.07
Torolopsis glabrata 3 0.1
Bacterial coinfections are frequent occurrences, and
should be screened for and treated promptly,
particularly in the setting of influenza A.
Fungal infections, though relatively rare, portend a
more grave prognosis.
Viral pneumonia is a common etiology of severe respiratory failure
requiring extracorporeal membrane oxygenation (ECMO). Bacterial and
fungal coinfections are relatively common, but their exact incidence has
yet to be described in this specific population.
More importantly than the incidence of these infections, however, is their
impact on patient outcomes. In the literature to date their remains a
relative paucity of data regarding associations between either general
classes of organisms to outcomes or between specific viruses and
infections with particular bacteria or fungi and how these impact outcomes.
The aim on this study was to better characterize the frequency of bacterial
and/or fungal coinfections in patients with viral pneumonias placed on
ECMO and to understand their impact on mortality.
Virus Survival % Median Age
Bacterial
coinfection
present %
Mortality
increased
with bacterial
coinfection?
Yeast
coinfection
present %
Mortality
increased
with Yeast
coinfection
RSV 65.9 0.3 [0.1, 1.1]
27.6
Not
Significant
5.6
Not
Significant
Pseudomon
as
aeruginosa
(4.6 %)
Candida
albicans
(1.9%)
Adenovirus 40.2 1 [0.1, 2.7]
27.4
Pseudomon
as
aeruginosa
(6.0%)
Not
Significant
11.7
0.002Candida
albcans
(3.6%)
Enterovirus 54.1 0.4 [0. 2.1]
33.40%
Not
Significant
6.7
Not
Significant
Pseudomon
as
aeruginosa
(4.9%)
Candida
albicans
(2.6%)
Influenza A 60.4
5.7 [1.2,
12.6]
39.00%
0.04
9.4
Not
SignificantMRSA
(9.8%)
Candida
albicans
(4.5)
Parainfluenz
a
65.6 1.2 [0.3, 4]
41
Not
Significant
7.1
Not
Significant
Pseudomon
as
aeruginosa
(8.7%)
Candida
albicans
(2.7%)
CMV 50.6 0.5 [0.1, 3.3]
32.3
Not
Significant
10.6
Not
Significant
Pseudomon
as
aeruginosa
(4.7%)
Candida
albicans
(6.5%)
HSV 30.7 0 [0, 0.6]
22.2
Not
Significant
11.8
Not
SignificantStaph. Epi
(3.9%)
Candida
albicans
(5.9%)
Influenza B 54.3 8 [1.8, 13.2]
38.6
Not
Significant
10.7
Not
Significant
Staph.
Aureus
(8.6%)
Candida
albicans
(4.3%)